Best of Five MCQs for the

Endocrinology and Diabetes SCE Atul

Kalhan
Visit to download the full and correct content document:
https://ebookmass.com/product/best-of-five-mcqs-for-the-endocrinology-and-diabetes
-sce-atul-kalhan/
OH$T
, O X F O R D H I G H E R SPECIALTY T R A I N I N G

BEST OF FIVE
MCQs FOR THE
ENDOCRINOLOGY
AND DIABETES SCE
Second Edition
Edited by
Atul Kalhan
Best of Five MCQs for the Endocrinology
and Diabetes SCE
Best of Five MCQs for
the Endocrinology
and Diabetes SCE

SECOND EDITION
Edited by
Professor Atul Kalhan
Consultant Diabetes and Endocrinology, Royal Glamorgan Hospital, Wales, UK
Honorary Consultant Endocrinologist, University Hospital of Wales, Cardiff, UK

1
3
Great Clarendon Street, Oxford, OX2 6DP,
United Kingdom
Oxford University Press is a department of the University of Oxford.
It furthers the University’s objective of excellence in research, scholarship,
and education by publishing worldwide. Oxford is a registered trade mark of
Oxford University Press in the UK and in certain other countries
© Oxford University Press 2022
The moral rights of the author have been asserted
First Edition published in 2015
Second Edition published in 2022
Impression: 1
All rights reserved. No part of this publication may be reproduced, stored in
a retrieval system, or transmitted, in any form or by any means, without the
prior permission in writing of Oxford University Press, or as expressly permitted
by law, by licence or under terms agreed with the appropriate reprographics
rights organization. Enquiries concerning reproduction outside the scope of the
above should be sent to the Rights Department, Oxford University Press, at the
address above
You must not circulate this work in any other form
and you must impose this same condition on any acquirer
Published in the United States of America by Oxford University Press
198 Madison Avenue, New York, NY 10016, United States of America
British Library Cataloguing in Publication Data
Data available
Library of Congress Control Number: 2021948691
ISBN 978–​0–​19–​886461–​5
DOI: 10.1093/​oso/​9780198864615.001.0001
Printed and bound by
CPI Group (UK) Ltd, Croydon, CR0 4YY
Oxford University Press makes no representation, express or implied, that the
drug dosages in this book are correct. Readers must therefore always check
the product information and clinical procedures with the most up-​to-​date
published product information and data sheets provided by the manufacturers
and the most recent codes of conduct and safety regulations. The authors and
the publishers do not accept responsibility or legal liability for any errors in the
text or for the misuse or misapplication of material in this work. Except where
otherwise stated, drug dosages and recommendations are for the non-​pregnant
adult who is not breast-​feeding
Links to third party websites are provided by Oxford in good faith and
for information only. Oxford disclaims any responsibility for the materials
contained in any third party website referenced in this work.
 FOREWORD

The clinical practice of diabetes and endocrinology has a breadth and a depth unrivalled in
contemporary medicine. The recognition that both the vascular endothelium and the adipocyte
should be considered as endocrine organs in their own right, the exponential increase in the
prevalence of Type 2 diabetes, obesity, and the metabolic syndrome, with their attendant clinical
sequelae, together with the more traditional endocrine disorders emphasizes the point. The broad
range of scientific disciplines ranges from molecular genetics through to medical biochemistry. This
breadth and depth confers a logistical challenge for the provision of appropriate comprehensive
clinical training for future specialists in the field.
This book is an excellent adjunct to the traditional textbooks. It is a comprehensive test of the
reader’s understanding of basic principles and is suitable for trainees at all levels. It is well written—​
clear and authoritative in style and very clinically orientated. It is translational in nature; that is, it
links basic science to clinical practice in a very innovative and relevant manner.
The authors are established experts in their field and are of a generation where their own training
programmes are a not too-​distant memory. This book deserves to be widely read. I shall be
strongly recommending it to all trainees in diabetes and endocrinology.
Dr Alan Rees BSc, MD, FRCP
Consultant Physician in Diabetes, Endocrinology,
and Clinical Lipidology
 PREFACE

It was winter of 2019 when I received an email from the editorial team at Oxford University Press,
pursuing a second edition of Best of Five MCQs for the Diabetes and Endocrinology SCE. The first
edition of the book was being appreciated by trainees from UK and all across the globe, exceeding
my initial limited expectations for it. However, by spring of 2020, as I was chalking up a timeline
to revise the book and publish it by the end of the year, a little pesky mRNA was proliferating at
a breakneck pace, obliterating geographic boundaries and inducing a state of mass paranoia. The
book revision was shelved as I, along with the majority of my colleagues, donned green scrubs to
man the frontline. It was only in spring of 2021 that I managed to attain the mindset and momentum
to work on this project.
The second edition of the book incorporates updated guidelines and the current evidence base into
MCQ discussion. I have tried to cover the basic sciences which form the building block for lifelong
knowledge in each chapter of the book. In addition, clinical scenarios have been inspired by real-​life
endocrinology practice.
I am thankful to Dr Ahmed Al-​Sharefi for his superb effort in updating the ‘Diabetes and lipid
metabolism’ chapter for this second edition. His work ethic and commitment make him a rising
star in the specialty. I am also thankful to Janine Fisher (Oxford University Press), who has provided
constant guidance and encouragement in each step of the book revision. Last, though not least,
I am indebted to my wife (Anu) and children (Amul and Anushka), who have been immensely
patient while I have spent long hours on my laptop engrossed in research articles and skimming
though guidelines.
Professor Atul Kalhan
FRCP (Edinburgh), MD (Cardiff University), MD (Delhi University), MRCPE
Consultant Diabetes and Endocrinology, Royal Glamorgan Hospital, Wales, UK
Honorary Consultant Endocrinologist, University Hospital of Wales, Cardiff, UK
 PREFACE (FIRST EDITION)

About a year and a half ago, huddled in one of the conference halls of the annual Diabetes UK
meeting in Manchester, me and my fellow diabetes and endocrinology colleagues wondered about
the lack of a written resource for the Specialty Certificate Exam (SCE), which was still in its early
years since inception. It was a more arduous task than we had anticipated and, at one stage, it
almost failed to take off, with the initial enthusiasm fading rapidly when faced with the practical
aspects of the complex task in hand. Only in the late winter of 2013, when the sun was making
its customary fleeting guest appearances, did I take it upon myself (with able support from my
colleagues) to burn the midnight oil and give shape to this dream.
This book contains more than 300 ‘best of five’ multiple-​choice questions, with explanatory
answers and up-​to-​date references/​guidelines. It is an attempt to provide diabetes and
endocrinology trainees with real-​life based clinical scenarios which will help them with the SCE
exam, besides bridging any gaps in knowledge.
I am thankful to Oxford University Press, and especially Geraldine and Fiona, for patiently guiding
me through the early phases of getting the correct format for the written text. I wish to express my
gratitude to Gautam, Vinay, and Rao for taking ownership of individual chapters and keeping spirits
high. Lastly, I am indebted, by the patience shown and constant encouragement provided, to my
wife Anu, who remained a pillar of support and took care of the little ones while I was glued to my
laptop writing/​editing the text.
Professor Atul Kalhan
 CONTENTS

Abbreviations xiii
Contributors xix

1 Pituitary gland and hypothalamus  1

Questions  1
Answers  38

2 Thyroid gland  57
Questions 57
Answers  89

3 Parathyroid gland and bone disease  113

Questions  113
Answers  141

4 Adrenal glands 161

Questions  161
Answers  186

5 Reproductive endocrinology  207

Questions 207
Answers 228

6 Diabetes and lipid metabolism  243

Questions  243
Answers 284

Index  307
 ABBREVIATIONS

11-​HSD2 11-​hydroxy steroid dehydrogenase 2

17-​OHP 17-​ hydroxy progesterone
3-​HSD 3-​hydroxy steroid dehydrogenase
ACE angiotensin-​converting enzyme
ACR albumin creatinine ratio
ACTH adrenocorticotropic hormone
ADA American Diabetes Association
ADH anti-​diuretic hormone
AF atrial fibrillation
AGHDA adult growth hormone deficiency assessment
AI adrenal insufficiency
AIH amiodarone-​induced hypothyroidism
AIP aryl hydrocarbon receptor-​interacting protein
AIS androgen insensitivity syndrome
AIT amiodarone-​induced thyrotoxicosis
ALP alkaline phosphatase
ALT alanine transaminase
AMH anti-​Müllerian hormone
anti-​TPO anti-​thyroid peroxidase
APA aldosterone-​producing adenoma
APCED autoimmune polyendocrinopathy-​candidiasis-​ectodermal dystrophy
ARR aldosterone to renin ratio
ATA American Thyroid Association
AVS adrenal venous sampling
BG blood glucose
BIPSS bilateral inferior petrosal sinus sampling
BMD bone mineral density
BP blood pressure
BTA British Thyroid Association
CAH congenital adrenal hyperplasia
CAS clinical activity score
xiv ABBREVIATIONS

CaSR calcium-​sensing receptor

CBG corticosteroid-​binding globulin
CBG capillary blood glucose
CD constitutional delay
CDGP constitutional delay in growth and puberty
CHH congenital hypogonadotrophic hypogonadism
CIR carbohydrate to insulin ratio
CKD chronic kidney disease
CRF clinical risk factor
CRH corticotropin-​releasing hormone
CRP C-​reactive protein
CSF cerebrospinal fluid
CTLA-​4 cytotoxic T lymphocyte antigen-​4
DDAVP desmopressin acetate
DHEA dehydroepiandrosterone
DHEA-​S dehydroepiandrosterone-​sulfate
DHT dihydrotestosterone
DI diabetes insipidus
DKA diabetic ketoacidosis
DM diabetes mellitus
DMPA depot medroxy progesterone
DOC deoxycorticosterone
DON dysthyroid optic neuropathy
DPP4 dipeptidyl peptidase inhibitors 4
DXA dual-​energy X-​ray absorptiometry
EASD European Association for the Study of Diabetics
eGFR estimated glomerular filtration rate
ESES European Society of Endocrine Surgeons
ETA European Thyroid Association
FFA free fatty acid
FGF23 fibroblast growth factor 23
FHH familial hypocalciuric hypercalcaemia
FIPA familial isolated pituitary adenomas
FNAC fine-​needle aspiration cytology
FSH follicle-​stimulating hormone
FSHoma FSH-​secreting pituitary adenoma
FT4 free thyroxine
GAD anti-​glutamic acid decarboxylase
GC glucocorticoid
 ABBREVIATIONS xv

GCK glucokinase
GCS Glasgow coma score
GD Graves’ disease
GDM gestational diabetes
GH growth hormone
GHD growth hormone deficiency
GHRH growth hormone releasing hormone
GLP-​1 glucagon-​like peptide
GnRH gonadotropin-​releasing hormone
GO Graves’ orbitopathy
GRA glucocorticoid remedial hyperaldosteronism
hCG human chorionic gonadotropin
HDL high-​density lipoprotein
HHS hyperosmolar hyperglycaemic state
HLA human leukocyte antigen
HNF hepatocyte nuclear factor
HPA hypothalamic–​pituitary–​adrenal
HPG hypothalmo–​pituitary–​gonadal
hPL human placental lactogen
HPLC high-​pressure liquid chromatography
HPT hyperparathyroidism
HPT-​JT hyperparathyroidism jaw tumour
HRT hormone replacement therapy
HSD hydroxyl steroid dehydrogenase
HU Hounsfield unit
IA islet antigen
ICA islet cell antigen
ICSI intra-​cytoplasmic sperm injection
IDF International Diabetes Federation
IGFBP insulin-​like growth factor-​binding protein
IL2 interleukin 2
IHA idiopathic hyperaldosteronism
IHD ischaemic heart disease
ITT insulin tolerance test
IVF in vitro fertilization
JBDS Joint British Diabetes Societies
LADA latent autoimmune diabetes of adulthood
LC-​MS liquid chromatography tandem-​mass spectrometry
LDDST low-​dose dexamethasone suppression test
xvi ABBREVIATIONS

LDL low-​density lipoprotein

LH luteinizing hormone
MDT multidisciplinary team
MEN multiple endocrine neoplasia
MODY maturity-​onset diabetes of the young
MR mineralocorticoid receptor
MTC medullary thyroid cancer/​carcinoma
NAFLD non-​alcoholic fatty liver disease
NCCAH non-​classic congenital adrenal hyperplasia
NFPA non-​functioning pituitary adenoma
NTIS non-​thyroidal illness syndrome
OCP oral contraceptive pill
ODST overnight dexamethasone suppression test
OGTT oral glucose tolerance test
P450 scc P450 side chain cleavage enzyme
PA primary hyperaldosteronism
PCOS polycystic ovarian/​ovary syndrome
PEG polyethylene glycol
PGL paraganglioma
PH phaeochromocytoma
PHP pseudohypoparathyroidism
PHPT primary hyperparathyroidism
PI pituitary incidentaloma
PKA protein kinase
PNMT 4-​phenyethanolamine-​N-​methyltransferase
POMC pro-​opio-​melano-​corticotropin
PPNAD primary pigmented nodular adrenocortical disease
PPT post-​partum thyroiditis
PRA plasma renin activity
PRL prolactin
PSA prostate specific antigen
PTH parathyroid hormone
PTHrP PTH-​related protein
PTU propylthiouracil
RAI radioactive iodine
RAIA radioactive iodine ablation
RAIU radioactive iodine uptake
RANK receptor activator of nuclear factor kappa
RRA radioiodine remnant ablation
 ABBREVIATIONS xvii

RTH resistance to thyroid hormones

scc side chain cleavage
SD standard deviation
SGLT2 sodium-​glucose co-​transporter 2
SH subclinical hyperthyroidism
SHBG sex hormone-​binding globulin
SHPT secondary hyperparathyroidism
SIADH syndrome of inappropriate anti-​diuretic hormone
SSTR somatostatin receptor subtype
SU sulphonylureas
TBG thyroxine-​binding globulin
TBII thyrotropin-​binding inhibitor immunoglobulin
TBPA thyroxine-​binding pre-​albumin
TFT thyroid function test
Tg thyroglobulin
TPO thyroid peroxidase
TPOAb thyreoperoxidase antibodies
TRAb TSH receptor antibodies
TRH thyrotropin-​releasing hormone
TSH thyrotropin-​stimulating hormone
TSHoma TSH-​secreting adenoma
TSH-​R TSH receptor
TTR transthyretin
UCaCr urinary calcium creatinine
UFC urinary free cortisol
VDDR vitamin D-​resistant rickets
VHL Von Hippel–​Lindau
VIP vasoactive intestinal peptide
VLCFA very long chain fatty acids
VRII variable-​rate insulin infusion
VRIII variable-​rate intravenous insulin infusion
 CONTRIBUTORS

Dr Ahmed Al-​Sharefi (Chapter 6)

Consultant Endocrinologist and Diabetologist, South Tyneside and Sunderland NHS Foundation
Trust, UK
Dr Fizzah Iqbal (Chapter 3)
Department of Diabetes and Endocrinology, Morriston Hospital, Swansea, UK
Professor Atul Kalhan (all chapters)
Consultant Diabetes and Endocrinology, Royal Glamorgan Hospital, Wales
Honorary Consultant Endocrinologist, University Hospital of Wales, Cardiff
 chapter PITUITARY GLAND
AND HYPOTHALAMUS
1 QUESTIONS

1. The pituitary gland is approximately 15×10×6 mm in size and weighs

500–​900 mg. It is located at the base of skull in a saddle-​shaped (sella
turcica, also known as pituitary fossa) portion of sphenoid bone. The
gland is surrounded by dura mater which also forms its roof (also known
as diaphragm sella).
Which of the following structures is located antero-​inferiorly to the
pituitary gland?
A. Cavernous sinus
B. Clinoid processes
C. Hypothalamus
D. Optic chiasm
E. Sphenoid sinus

2. Anterior pituitary cells are classified according to their staining

properties and by their specific secretory products, which can be
identified by immunocytochemical and electron microscopic techniques.
Which one of the following is the most abundant cell population of the
anterior pituitary gland?
A. Corticotrophs
B. Gonadotrophs
C. Lactotrophs
D. Somatotrophs
E. Thyrotrophs

Best of Five MCQs for the Endocrinology and Diabetes SCE. Atul Kalhan, Oxford University Press. © Oxford University Press 2022.
DOI: 10.1093/​oso/​9780198864615.003.0001
2 Chapter 1 | QUESTIONS

3. A 23-​year-​old woman was referred to the medical assessment unit with an

intermittent headache lasting 6 weeks. There was no history of associated
visual symptoms associated with the headache. She had used paracetamol
tablets (prn) for the headache with partial relief of symptoms. She was
previously well and not on any regular medication. Her menstrual cycles
were regular and there was no history of galactorrhoea. On examination,
she was systemically well. Her visual fields were normal on confrontation
testing. There were no features of hypercortisolism or acromegaly.
Investigations:
Insulin Growth Factor 1 35 nmol/​L (16–​118)
Prolactin 845 mU/​L (60–​620)
FT4 14.5 pmol/​L (11.5–​22.7)
TSH 0.8 mU/​L (0.35–​5.5)
9 a.m. cortisol 405 nmol/​L
 Chapter 1 | QUESTIONS 3

MRI of the pituitary was arranged to evaluate the cause of her headache
(see Fig. 1.1).

(a) (b)

(c) (d)

Fig. 1.1 T1-​weighted MRI image, sagittal view

Which of the following is the most appropriate management approach

in her case?
A. Cabergoline
B. Observation
C. Radiotherapy
D. Somatostatin analogues
E. Trans-​sphenoidal surgery
4 Chapter 1 | QUESTIONS

4. The hypothalamic hormones are mainly of two subtypes: (a)

hypophysiotropic hormones which are directly secreted into the portal
blood flow and control anterior pituitary hormone synthesis/​secretion;
(b) neurohormones which are stored in the posterior pituitary gland.
Which of the following hypothalamic hormones is associated with
inhibition of TSH secretion?
A. Corticotropin-​releasing hormone (CRH)
B. Dopamine
C. Growth hormone releasing hormone (GHRH)
D. Somatostatin
E. Oxytocin

5. The secretion of adrenocorticotropic hormone (ACTH) follows a

circadian rhythm with peak levels seen from 6 a.m. to 9 a.m., while
the nadir is seen around 11 p.m. to 2 a.m. ACTH release is under the
influence of various pituitary and non-​pituitary hormones.
Which one of the following hormones is associated with decreased
ACTH release?
A. Catecholamine
B. Corticotropin-​releasing hormone (CRH)
C. Endocannabinoids
D. Ghrelin
E. Vasoactive intestinal peptide

6. Growth hormone (GH) is secreted in a pulsatile manner, with around

5–​10 pulses seen in a period of 24 hours. Women have higher mean GH
levels compared with men.
Which one of the following factors/​conditions is associated with
increased GH secretion?
A. Ageing
B. Increased BMI
C. Lack of exercise
D. Lack of sleep
E. Protein meal
 Chapter 1 | QUESTIONS 5

7. Ghrelin, an important GH secretogogue, circulates mostly as the des-​

octanoylated form bound to a subfraction of high-​density lipoprotein
(HDL) particle.
Which one of the following is a biological action of ghrelin during normal
physiological states?
A. Decreased feeding
B. Decreased utilization of metabolic substrates
C. Increased gastric emptying
D. Inhibition of GH secretion
E. Inhibition of insulin secretion

8. Vasopressin (antidiuretic hormone) is a nine-​amino acid polypeptide

that is synthesized in the hypothalamus and stored in the posterior
pituitary. It acts as an important regulator of fluid and electrolyte
balance.
Which one of the following is a known biological effect of vasopressin?
A. Decreased ACTH secretion
B. Decreased glycogenolysis
C. Increased platelet adhesion
D. Increased water reabsorption from the proximal nephron
E. Inhibition of smooth muscle contraction

9. Vasopressin secreted from the posterior pituitary gland has osmo-​and

baro-​regulatory functions.
Which one of the following factors is associated with decreased
vasopressin release from the posterior pituitary gland?
A. Germinoma
B. Head injury
C. Increasing age
D. Low blood pressure
E. Lower respiratory infection

10. Oxytocin is a nine-​amino acid polypeptide secreted from the posterior

pituitary, with most of its known or postulated physiological effects
related to reproductive function in mammals.
Which of the following is believed to be a physiological action of
oxytocin, based on animal and human studies?
A. Increased appetite
B. Inhibition of insulin secretion
C. Lipolysis
D. Muscle and bone catabolism
E. Reduced uterine contractions
6 Chapter 1 | QUESTIONS

11. There are five major somatostatin receptor subtypes (SSTR 1–​5)
expressed in various organs in the body.
Which one of the following combinations of subtypes of SSTRs is most
commonly expressed in GH-​secreting pituitary adenomas?
A. SSTR-​1 and SSTR-​2
B. SSTR-​1 and SSTR-​5
C. SSTR-​2 and SSTR-​5
D. SSTR-​3 and SSTR-​4
E. SSTR-​4 and SSTR-​5

12. A 33-​year-​old woman presented to the endocrine clinic with weight

gain, easy bruisability, and fatigue during the third trimester of her
pregnancy. On examination, she had high blood pressure and stria on
the lower abdomen. Further blood investigations showed impaired
glucose tolerance on oral glucose tolerance test. A clinical suspicion
of Cushing’s syndrome was raised and she underwent further
evaluation.
Which one of the following physiological changes is seen in the ACTH-​
cortisol axis during normal pregnancy?
A. Blunting of cortisol response to dexamethasone suppression test
B. Loss of diurnal rhythm of cortisol secretion
C. Lowered cortisol-​binding globulin levels
D. Lowered cortisol levels
E. Urinary free cortisol levels five times the normal (non-​pregnancy) range

13. Glycoprotein hormones are characterized by a common α subunit

and hormone-​specific β subunit. In contrast, peptide hormones are
synthesized from amino acids and typically generated as prohormones,
which may be secreted in the circulatory system following a specific
stimulus.
Which one of the following is a peptide hormone secreted in the human
body under normal physiological state?
A. Adrenocorticotropic hormone (ACTH)
B. Follicle-​stimulating hormone (FSH)
C. Human chorionic gonadotropin (hCG)
D. Luteinizing hormone (LH)
E. Thyrotropin-​stimulating hormone (TSH)
 Chapter 1 | QUESTIONS 7

14. A 54-​year-​old man presented to the endocrine clinic with gradually

worsening low mood, malaise, and reduced exercise capacity. He was
known to have dyslipidaemia and ischaemic heart disease (IHD). He was
operated on previously for a non-​functioning pituitary adenoma (NFPA)
resulting in partial anterior hypopituitarism, and had been on thyroxine
and hydrocortisone replacement therapy. On examination, he had a BMI
of 35 kg/​m2 with evidence of central adiposity.
Investigations:
9 a.m. cortisol 415 nmol/​L
IGF-​1 8 nmol/​L (16–​118)
FT4 15.4 pmol/​L (11.5–​22.7)
TSH 0.03 mU/​L (0.35–​5.5)
Which one of the following tests is most appropriate in his case to
confirm the diagnosis of adult GH deficiency?
A. Domeperidone test
B. GH levels
C. GHRH-​arginine stimulation test
D. Insulin-​like growth factor-​binding protein (IGFBP) measurement
E. Insulin tolerance test

15. A 43-​year-​old teacher was reviewed in the endocrine clinic for symptoms of
low mood and lethargy. She had undergone trans-​sphenoidal resection of a
NFPA 5 years before, and was on thyroxine and hydrocortisone replacement
therapy. She was also on zonisamide therapy for focal seizures.
Investigations:
Prolactin 270 mU/​L (45–​375)
IGF-​1 8 nmol/​L (16–​118)
FT4 15.4 pmol/​L (11.5–​22.7)
TSH 0.03 mU/​L (0.35–​5.5)
Which one of the following tests is most appropriate to assess her
suspected GH deficiency?
A. GH levels
B. Glucagon stimulation test
C. Glucose tolerance test
D. IGFBP3 levels
E. Insulin tolerance test
8 Chapter 1 | QUESTIONS

16. A 66-​year-​old retired police officer presented to the endocrine clinic

with low mood, reduced exercise tolerance, and malaise. He had
undergone trans-​sphenoidal resection of a NFPA 5 years before
and post-​operatively developed partial anterior pituitary hormone
deficiency. He also had a past medical history of prostate cancer
(T2N0M0), which was cured by post-​elective resection. At the time of
presentation, he was on hydrocortisone, thyroxine, and testosterone
replacement therapy.
Investigations:
IGF-​1 6 nmol/​L (16–​118)
Prolactin 186 mU/​L (45–​375)
FT4 16.5 pmol/​L (11.5–​22.7)
TSH 0.11 mU/​L (0.35–​5.5)
LFT Normal
Which one of the following is the most appropriate next step in his
management?
A. Confirm the GH deficiency with a dynamic test
B. GH contraindicated due to potential risk of tumour growth
C. Reduce thyroxine dose
D. Start GH therapy
E. Start octreotide

17. A 52-​year-​old man presented to the endocrine clinic with symptoms

of reduced sexual drive. He smoked five or six cigarettes a day and
denied use of any substance of abuse. On examination, he had a BMI of
45 kg/​m2 with evidence of central obesity and normal secondary sexual
characteristic development with no anosmia.
Investigations:
FSH 1.5 U/​L (1.4–​18.1)
LH 3.1 U/​L (3–​8)
Testosterone 5.5 nmol/​L (8.5–​28.5)
Brain MRI Normal pituitary gland
Which one of the following is the most likely aetiology for his reduced
libido and hypogonadism?
A. Idiopathic
B. Increased BMI
C. Kallmann syndrome
D. Klinefelter’s syndrome
E. Sheehan’s syndrome
 Chapter 1 | QUESTIONS 9

18. A 65-​year-​old man presented to the accident and emergency unit with
sudden-​onset headache, nausea, and vomiting. On examination, he
was drowsy with features of third, fourth, and sixth cranial nerve palsy.
Urgent MRI of the brain was arranged (see Fig. 1.2).

Fig. 1.2 MRI of the pituitary gland, sagittal view

Which of the following is not an indication for urgent neurosurgical

intervention in a patient with pituitary apoplexy?
A. Deteriorating level of consciousness
B. Ocular paresis (third, fourth, and sixth cranial nerves)
C. Severe and persistent visual-​field defect
D. Severely reduced visual acuity
E. Worsening visual-​field defect
10 Chapter 1 | QUESTIONS

19. A 17-​year-​old boy presented to the endocrine clinic with features

of delayed puberty. On examination, he had a reduced sense of
smell, small-​sized testes, and under-​developed secondary sexual
characteristics.
Investigations:
FSH 1.2 U/​L (1.4–​18.1)
LH 1.5 U/​L (3–​8)
Testosterone 4.4 nmol/​L (8.5–​28.5)
Brain MRI Normal pituitary gland
Which one of the following agents is the most useful therapeutic
intervention to restore fertility in this clinical scenario?
A. Cabergoline
B. Clomiphene
C. hCG +​ FSH
D. Octreotide
E. Testosterone replacement

20. A 26-​year-​old man was referred to the endocrine clinic with a history
of decreased libido and erectile dysfunction. On examination, he was
1.85 m tall with a BMI of 25 kg/​m2. He had sparse facial and pubic hair,
gynaecomastia, small testicles (right 2 mL and left 3 mL), and there was
no anosmia.
Investigations:
FSH 31 U/​L (1.4–​18.1)
LH 12 U/​L (3.0–​8.0)
Testosterone 4.8 nmol/​L (8.4–​28.7)
FT4 21.6 pmol/​L (11.5–​22.7)
TSH 0.5 mU/L (0.35–​5.5)
Prolactin 640 mU/​L (100–​550)
Which one of the following is the most likely diagnosis in this clinical
scenario?
A. FSH-​secreting pituitary adenoma (FSHoma)
B. Kallmann syndrome
C. Klinefelter’s syndrome
D. Prolactinoma
E. Thyrotoxicosis
 Chapter 1 | QUESTIONS 11

21. An 18-​year-​old boy with idiopathic GH deficiency was reviewed in the

adult endocrine clinic for the first time. He had initially presented to
the paediatric endocrine clinic with delayed growth and was noticed to
have features consistent with GH deficiency, which was subsequently
confirmed with dynamic testing. He showed good response with GH
replacement therapy.
Investigations:
IGF-​1 32 nmol/​L (16–​118)
Prolactin 225 mU/​L (45–​375)
FT4 14.5 pmol/​L (11.5–​22.7)
TSH 2.5 mU/​L (0.35–​5.5)
Which one of the following is the most appropriate management
approach when he is reviewed in the adult endocrine clinic?
A. Decrease the GH replacement dose
B. Increase the GH replacement dose
C. No change in the GH replacement dose
D. Stop the GH replacement
E. Stop the GH replacement and reassess the GH axis

22. A 48-​year-​old man presented to the endocrine clinic with symptoms

of low mood, malaise, and loss of muscle mass. He was known to
have partial anterior pituitary hormone deficiency and was on
hydrocortisone, testosterone, and thyroxine replacement therapy.
Investigations:
IGF-​1 6 nmol/​L (16–​118)
Testosterone 14.5 nmol/​L (9–​25)
FT4 18.4 pmol/​L (11.5–​22.7)
TSH 0.04 mU/​L (0.35–​5.5)
Which one of the following is the most appropriate step in his further
management?
A. Arrange arginine-​GHRH stimulation test
B. Arrange insulin tolerance test
C. Increase thyroxine dose
D. Reduce thyroxine dose
E. Start GH replacement
12 Chapter 1 | QUESTIONS

23. A 45-​year-​old woman with a background history of growth hormone

deficiency (GHD) was reviewed in the endocrine clinic on a routine visit.
She had been on GH replacement therapy for the previous year and
had shown improvement in her quality of life as assessed by adult GHD
assessment (AGHDA) scores.
Which one of the following metabolic changes is associated with GH
replacement therapy?
A. Decrease in exercise capacity
B. Decrease in triglyceride levels
C. Increase in bone mineral density
D. Increase in low-​density lipoprotein (LDL) cholesterol
E. Unchanged lean body mass

24. A 41-​year-​old woman presented to the accident and emergency

department with a history of sudden-​onset severe headache, nausea,
vomiting, and visual disturbance. On examination, she was apyrexial,
hypotensive, and tachycardic, with no features of meningism. She also
had evidence of third, fourth, and sixth cranial nerve palsies. MRI was
arranged (see Fig. 1.3).

Fig. 1.3 MRI of the pituitary gland, coronal view

 Chapter 1 | QUESTIONS 13

Which one of the following is a correct statement regarding the

management of pituitary apoplexy?
A. Daily formal assessment of visual field and acuity is indicated in patients with reduced visual
acuity or defective visual fields
B. Steroid therapy is indicated in patients, based on short synacthen test results
C. Surgical management is indicated in all patients, irrespective of severity of visual-​field
defects
D. Urgent neurosurgical intervention is indicated in all patients, with or without a significant
decline in level of consciousness
E. Urgent neurosurgical intervention is indicated in patients with pituitary apoplexy showing
ocular paresis
14 Chapter 1 | QUESTIONS

25. A 46-​year-​old nurse presented with symptoms of menstrual

irregularities, lethargy, and mood swings. She had also noticed milky
discharge from the nipples for the previous 2 months. She was a known
hypertensive, currently on amlodipine and doxazosin therapy. On
examination, her visual fields were normal on confrontation testing.
Investigations:
FSH 32 U/​L (follicular 0.5–​5, mid-​cycle 8–​33, luteal 2–​8)
LH 76 U/​L (follicular 3–​12, mid-​cycle 20–​80, luteal 3–​16)
Oestradiol 18 pmol/​L (follicular 17–​260, luteal 180–​1100)
IGF-​1 34 nmol/​L (16–​118)
Prolactin 902 mU/​L (45–​375)
FT4 8.2 pmol/​L (11.5–​22.7)
TSH 16.8 mU/​L (0.35–​5.5)
Urine for pregnancy test Negative
Which one of the following is the most likely explanation for her hyper-​
prolactinaemia and galactorrhoea?
A. Amlodipine
B. Doxazosin
C. Hypothyroidism
D. Prolactinoma
E. Menopause

26. A 20-​year-​old university student presented with a 3-​year history of

ongoing menstrual irregularities and intermittent headaches. She is on
oral contraceptive pills for last 2 years. On examination, she had a BMI
of 27 kg/​m2, with normal general physical and systemic examination,
except for excessive facial hair growth.
Investigations:
FSH 0.3 U/​L (follicular 0.5–​5, mid-​cycle 8–​33, luteal 2–​8)
LH 0.1 U/​L (follicular 3–​12, mid-​cycle 20–​80, luteal 3–​16)
Oestradiol 225 pmol/​L (follicular 17–​260, luteal 180–​1100)
Prolactin 704 mU/​L (45–​375 mU/​L)
FT4 12.8 pmol/​L (11.5–​22.7)
TSH 5.5 mU/​L (0.35–​5.5)
Testosterone 2.4 nmol/​L (<1.5)
Which one of the following is the most likely cause for her elevated
prolactin levels?
A. Hypothyroidism
B. Non-​functional pituitary adenoma
C. Polycystic ovarian disease
D. Pregnancy
E. Prolactinoma
 Chapter 1 | QUESTIONS 15

27. A 26-​year-​old woman presented with a 4-​month history of secondary

amenorrhoea and episodic throbbing headache, together with visual
symptoms (wavy lines and circles in front of the eyes). She had a past
medical history of microprolactinoma, diagnosed 4 years before whilst
being investigated for infertility, and had been on cabergoline therapy.
Investigations:
Prolactin 1404 mU/​L (45–​375 mU/​L)
FT4 16.5 pmol/​L (11.5–​22.7 pmol/​L)
TSH 0.6 mU/​L (0.35–​5.5 mU/​L)
Which one of the following is the most appropriate next step in her
further management?
A. Switch to bromocriptine
B. Switch to quinagolide
C. Urgent MRI of the pituitary
D. Urgent visual-​field assessment
E. Take urine for pregnancy test

28. A 31-​year-​old staff nurse with macroprolactinoma presented in the

accident and emergency department with sudden onset of headache
and visual disturbance while she was 8 months pregnant. She had
previously been on cabergoline therapy, which was stopped when her
pregnancy was confirmed, after an informed discussion.
An urgent visual-​field assessment showed no visual-​field defect. MRI of
the pituitary showed an increase in size of prolactinoma in proximity to
the optic chiasm.
Which one of the following is the most appropriate immediate step in
her management?
A. Induction of delivery
B. Restart cabergoline therapy
C. Start bromocriptine therapy
D. Urgent neurosurgical intervention
E. Urgent radiotherapy
16 Chapter 1 | QUESTIONS

29. A 22-​year-​old woman was referred to the endocrine clinic with

incidentally detected elevated prolactin levels, while she was being
investigated for excessive facial hair growth. She had no history of
galactorrhoea and her menstrual cycles were regular. Her general
physical and systemic examination was unremarkable. MRI of the
pituitary was inconclusive, with midline pituitary stalk and no obvious
lesion identified.
Investigations:
IGF-​1 18 nmol/​L (16–​118)
Prolactin 905 mU/​L (60–​620)
FT4 14.5 pmol/​L (11.5–​22.7)
TSH 5.5 mU/​L (0.35–​5.5)
9 a.m. cortisol 410 nmol/​L
Which one of the following is the most likely explanation for her
elevated prolactin levels?
A. Hook effect
B. Hypothyroidism
C. Infiltrative hypothalamic lesion
D. Macroprolactin
E. Non-​functioning pituitary microadenoma

30. A 28-​year-​old woman presented to the endocrine clinic with secondary

amenorrhoea and galactorrhoea for the previous 6 months. Her general
physical and systemic examination was normal. MRI of the pituitary
gland confirmed the presence of a microadenoma. She was quite keen
to start a family within the coming few months and sought advice
regarding further management.
Investigations:
Prolactin 3250 mU/​L (60–​620)
FT4 15.5 pmol/​L (11.5–​22.7)
TSH 2.5 mU/​L (0.35–​5.5)
Urine pregnancy test Negative
Which one of the following is the most appropriate therapeutic option
in her case?
A. Bromocriptine
B. Elective trans-​sphenoidal surgery
C. Octreotide
D. Quinagolide
E. Radiotherapy
 Chapter 1 | QUESTIONS 17

31. A 65-​year-​old woman presented to the diabetes clinic with worsening

glycaemic control. She had recently been diagnosed with carpel tunnel
syndrome and was awaiting an elective procedure. On examination, she
had a coarse facial appearance, increased inter-​dentate space, together
with relatively big hands and feet.
Investigations:
IGF-​1 102 nmol/​L (16–​118)
Prolactin 610 mU/​L (45–​375)
FT4 12.5 pmol/​L (11.5–​22.7)
TSH 1.5 mU/​L (0.35–​4.5)
Which one of the following is the most appropriate next step in
her immediate management, while she is awaiting MRI of the
pituitary gland?
A. Domperidone test
B. Glucose tolerance test
C. Insulin tolerance test
D. Start bromocriptine
E. Start cabergoline

32. A 22-​year-​old woman known to have an aggressive GH tumour was

reviewed in the endocrine clinic for further management. She was
awaiting radiotherapy after an incomplete cure was achieved with trans-​
sphenoidal surgery. She had a strong family history of GH-​secreting
tumours.
Which one of the following mutations is associated with an increased
risk of aggressive familial non-​functioning and GH-​secreting pituitary
adenomas?
A. Aryl hydrocarbon receptor-​interacting protein
B. Menin
C. RET proto-​oncogene
D. Succinate dehydrogenase B and D
E. Succinate dehydrogenase C
18 Chapter 1 | QUESTIONS

33. A 48-​year-​old teacher was referred to the endocrine clinic by his dentist
in view of suspected acromegalic features. He had been under dental
follow-​up in view of jaw pain and was noticed to have an increased
inter-​dentate space, protruding of the jaw, and coarsening of facial
features. He had a background of Type 2 diabetes mellitus (DM) and
osteoarthritis. On examination, he had prognathism, thickened lips, and
large hands. His initial baseline biochemical test showed increased IGF-​1
levels, and an oral glucose tolerance test was arranged to confirm GH
excess. The patient underwent further assessment and counselling for
co-​morbidities and disorders associated with acromegaly.
Which of the following is the correct approach considering association of
acromegaly with colonic polyps?
A. A baseline colonoscopy should be done in all children and adults
B. If baseline colonoscopy is normal, repeat colonoscopy is not required
C. If baseline/​surveillance colonoscopy shows adenoma, repeat colonoscopy should be
carried out every 3–​5 years
D. If IGF-​1 levels remain persistently elevated, colonoscopy needs to be carried out on
yearly basis
E. The surveillance for colonic polyps should only start at age 50 years

34. A 45-​year-​old bus driver underwent elective trans-​sphenoidal surgery

for his GH-​secreting macroadenoma. Post-​operatively, his IGF-​1 levels
remained elevated, along with unsuppressed GH levels after the glucose
tolerance test, suggestive of an incomplete cure surgically. He was
started on somatostatin analogue therapy, although he failed to respond
to it. In view of the ongoing symptoms and raised IGF-​1 levels, he was
considered for pegvisomant therapy while awaiting a multidisciplinary
team decision regarding repeat surgery or cranial irradiation.
Which one of the following clinical/​biochemical changes is associated
with pegvisomant therapy?
A. Increase in GH levels
B. Increase in IGF-​1 levels
C. Increased risk of development of gallstones
D. Increased risk of pituitary tumour regrowth
E. Worsening of glycaemic control
 Chapter 1 | QUESTIONS 19

35. A 17-​year-​old boy was referred to the endocrine clinic with features of
short height and weight gain. On examination, he had an increased BMI
and central adiposity, together with purple striae on the lower abdomen.
Investigations:
24-​hour urine-​free cortisol 268 nmol/​24 hours (<146)
11 p.m. salivary cortisol 6.5 nmol/​L (<3.1)
Low-​dose dexamethasone suppression test (LDDST):
48-​hour cortisol 380 nmol/​L (<50)
ACTH 56.7 ng/​L (<51)
Which one of the following is the most appropriate next step in his
management?
A. Bilateral inferior petrosal sinus sampling (BIPSS)
B. CT of the abdomen
C. CT of the abdomen and thorax
D. MRI of the pituitary
E. Octreotide scan

36. A 52-​year-​old shop assistant presented with a 6-​month history of

diminishing exercise capacity and reduced libido. He was currently
taking bisoprolol and terazosin tablets for blood pressure control. His
general physical and systemic examination was normal.
Investigations:
9 a.m. cortisol 40 nmol/​L (>300)
FSH 2.5 U/​L (1.4–​18.1)
LH 1.9 U/​L (3.0–​8.0)
Testosterone 7.5 nmol/​L (9–​25)
Prolactin 855 mU/​L (45–​375)
IGF-​1 35 nmol/​L (16–​118)
FT4 9.5 pmol/​L (11.5–​22.7)
TSH 0.15 mU/​L (0.35–​5.5 mU/​L)
Which one of the following is the most likely cause for his elevated
prolactin levels?
A. Pituitary stalk compression
B. Prolactinoma
C. Secondary hypothyroidism
D. Terazosin
E. Thyrotoxicosis
20 Chapter 1 | QUESTIONS

37. A 45-​year-​old lorry driver was referred to the endocrine clinic with
symptoms of reduced libido and lack of energy. He had history of a
traumatic head injury 5 years previously, which needed a period of 24
hours’ observation in hospital. On examination, his BMI was 42 kg/​m2,
with normal general physical and systemic examination.
Investigations:
FT4 8.1 pmol/​L (11.5–​22.7)
TSH 0.4 mU/​L (0.35–​5.5)
FSH 2.2 U/​L (1.4–​18.1)
LH 3.5 U/​L (3.0–​8.0)
Testosterone 6.8 nmol/​L (8.4–​28.7)
IGF-​1 35 nmol/​L (16–​118)
Prolactin 880 mU/​L (45–​375)
Which one of the following is the most likely diagnosis, based on his
clinical profile?
A. Microprolactinoma
B. Morbid obesity
C. Non-​functioning pituitary adenoma
D. Post-​traumatic pituitary apoplexy
E. Primary hypothyroidism

38. The pituitary gland is composed of acidophilic (somatotrophs and

lactotrophs) and basophilic (corticotrophs, thyrotrophs, gonadotrophs)
or chromophobe cells based on histochemical staining with pH-​
dependent dyes.
Which one of the following is generally the correct order of involvement
of cells secondary to a compressive NFPA?
A. Corticotrophs > thyrotrophs > somatotrophs > gonadotrophs
B. Gonadotrophs > thyrotrophs > corticotrophs > somatotrophs
C. Gonadotrophs > thyrotrophs > somatotrophs > corticotrophs
D. Somatotrophs > gonadotrophs > thyrotrophs > corticotrophs
E. Thyrotrophs > somatotrophs > corticotrophs > gonadotrophs
 Chapter 1 | QUESTIONS 21

39. A 55-​year-​old woman presented to the clinic with symptoms of

recurrent headaches and galactorrhoea. Her general physical and
systemic examination was unremarkable. Her formal visual-​field
assessment did not reveal any field defect. Her anterior pituitary
hormone profile reassuringly showed results that are within normal
range except for a slightly elevated prolactin level. MRI of the pituitary
gland confirmed the presence of a pituitary macroadenoma with
extensive involvement of the cavernous sinus.
Which one of the following is the most appropriate management
approach in her case?
A. Cabergoline
B. Conservative management
C. Gamma knife radiosurgery
D. Octreotide therapy
E. Transfrontal craniotomy
22 Chapter 1 | QUESTIONS

40. A 75-​year-​old retired army man was referred to the endocrine clinic
with symptoms including recurrent headaches, lethargy, and malaise.
His general physical and systemic examination was unremarkable.
Investigations:
FT4 6.8 pmol/​
L          (11.5–​
22.7)
TSH 0.5 mU/​
L           (0.35–​
5.5)
FSH 1.0 U/​
L            (1.4–​
18.1)
LH 2.5 U/​
L            (3.0–​
8.0)
Testosterone 8.5 nmol/​
L          (8.4–​
28.7)
Prolactin 655 mU/​
L           (45–​
375)
9 a.m. cortisol 381 nmol/​L
MRI of the pituitary was undertaken (see Fig. 1.4).

Fig. 1.4 MRI of the pituitary gland, coronal view

Which one of the following is a definitive indication for elective surgery

in a patient with NFPA?
A. Abnormal short synacthen test results
B. Optic chiasm compression
C. Recurrent headaches
D. Secondary hypothyroidism
E. Tumour size
 Chapter 1 | QUESTIONS 23

41. A 70-​year-​old man was referred to the endocrine clinic with 6-​week history
of headache and visual disturbance. On examination, he had a bitemporal
visual-​field defect, which was confirmed on formal visual-​field assessment.
Investigations:
FT4 8.5 pmol/​
L        (11.5–​
22.7)
TSH 0.5 mU/​
L         (0.35–​
5.5)
FSH 1.0 U/​
L          (1.4–​
18.1)
LH 2.5 U/​
L          (3.0–​
8.0)
Prolactin 800 mU/​
L         (45–​
375)
Testosterone 3.5 nmol/​
L        (8.4–​
28.7)
9 a.m. cortisol 405 nmol/​L
MRI showed a pituitary adenoma with suprasellar extension (see Fig. 1.5).

Fig. 1.5 MRI of the pituitary gland, sagittal view

Which one of the following is the most appropriate definitive

management approach for him?
A. Cabergoline
B. Hormone replacement (thyroxine and testosterone)
C. Neurosurgical referral
D. Radiotherapy
E. Somatostatin analogues
24 Chapter 1 | QUESTIONS

42. A 22-​year-​old woman presented with a history of menstrual

irregularities for the previous 4 years. She had attained menarche at
the age of 13 years. Her general physical and systemic examination was
unremarkable. Ultrasound of the pelvis showed bilateral enlarged and
cystic ovaries. MRI of the pituitary showed an 18-​mm pituitary tumour
without any involvement of the optic chiasm.
Investigations:
FSH 45 U/​L (follicular 0.5–​5, mid-​cycle 8–​33, luteal 2–​8)
LH 2.5 U/​L (follicular 3–​12, mid-​cycle 20–​80, luteal 3–​16)
Oestradiol 1332 pmol/​L (follicular 17–​260, luteal 180–​1100)
Prolactin 604 mU/​L (45–​375)
Which one of the following is the most likely diagnosis in her case?
A. Ectopic oestrogen-​secreting tumour
B. Gonadotropin-​secreting adenoma
C. Non-​functioning pituitary adenoma
D. Ovarian hyperstimulation syndrome
E. Polycystic ovarian syndrome with a pituitary incidentaloma

43. A 47-​year-​old post-​menopausal woman presented to the endocrine

clinic with a 6-​month history of palpitations, increasing shortness of
breath, and weight loss. Her general physical and systemic examination
was unremarkable. Her thyroid function test (TFT) results were
as shown:
FT4 24.8 pmol/​L (9.0–​19.1)
FT3 7.4 pmol/​L (2.6–​5.7)
TSH 6.15 mU/L (0.35–​5.0)
Which one of the following clinical/​biochemical features is consistent
with a diagnosis of TSH-​secreting pituitary adenoma (TSHoma)?
A. α subunit/​TSH ratio <1
B. Absence of goitre
C. Increased TSH post-​TRH stimulation test
D. Non-​suppression of TSH on T3 suppression test
E. Reduced sex hormone-​binding globulin (SHBG) levels
 Chapter 1 | QUESTIONS 25

44. A 66-​year-​old man presented with a 4-​month history of weight loss,

increased sweating, and palpitations. His general physical and systemic
examination was unremarkable except for mild resting tremors and the
presence of a small goitre. His TFT results were as shown:
FT3 6.5 pmol/​L (2.6–​5.7)
FT4 25.0 pmol/​L (11.5–​22.7)
TSH 5.8 mU/​L (0.35–​5.5)
Which one of the following will be a useful test to establish the possible
underlying diagnosis?
A. Thyreoperoxidase antibodies (TPOAb)
B. Thyroid ultrasound
C. Thyroid uptake scan
D. TRH test with TSH
E. TSH receptor antibodies (TRAb)

45. A 78-​year-​old man was referred to the endocrine clinic with a 6-​month
history of weight loss, increased sweating, and tremors. He had a
background history of severe congestive cardiac failure and end-​stage
renal failure. On examination, he had a smooth small goitre, bilateral
tremors, and bi-​basal crepitations on auscultation of the lungs.
Investigations:
FT4 26.5 pmol/​L (11.5–​22.7 pmol/​L)
FT3 9.1 pmol/​L (3.5–​6.5 pmol/​L)
TSH 8.5 mU/​L (0.35–​5.5 mU/​L)
The remaining anterior pituitary hormone profile was within normal
range. Heterophile antibodies were negative. MRI of the pituitary
showed a 15-​mm pituitary adenoma, which was not compressing
the optic chiasm. During the combined neurosurgical-​endocrine
multidisciplinary team meeting, a decision was made to manage him
with medical therapy, considering his co-​morbidities.
Which one of the following is the treatment of choice for his further
management?
A. Cabergoline
B. Carbimazole
C. Octreotide
D. Radioactive iodine (RAI) ablation
E. Stereotactic Radiotherapy
26 Chapter 1 | QUESTIONS

46. Non-​functioning pituitary adenoma (NFPA) are the commonest pituitary

tumours, which account for approximately 90% of sellar masses, and may
be detected incidentally or present with pressure symptoms.
Which one of the following is the commonest pattern/​finding seen on
immunostaining of a NFPA?
A. Gonadotropins
B. No immunostaining
C. Non-​specific immunostaining
D. Prolactin
E. Somatostatin

47. A 36-​year-​old woman was incidentally detected to have a 6-​mm pituitary

micro-​adenoma on MRI of the head arranged to evaluate the cause
for her recurrent headaches. Apart from the headaches that she had
suffered for the previous 6 months, she had no past history of any
significant medical illness and was not on any regular medications. Her
general physical and systemic examination was unremarkable.
Which one of the following is the most appropriate next step in her
management?
A. Anterior pituitary hormone profile
B. Discharge from follow-​up
C. Formal visual-​field assessment
D. Neurosurgical referral
E. Repeat MRI in 6 months
 Chapter 1 | QUESTIONS 27

48. A 41-​year-​old man was incidentally detected to have a pituitary tumour

measuring 5 mm on a CT scan of the head done after a traumatic head
injury. He had no significant past medical history and was not on any
regular medications. His general physical and systemic examination was
unremarkable.
Investigations:
IGF-​1 30 nmol/​L (16–​118)
Prolactin 262 mU/​L (60–​620)
Testosterone 9.4 nmol/​L (8.5–​28.5)
FT4 15.5 pmol/​L (11.5–​22.7)
TSH 3.0 mU/​L (0.35–​5.5)
9 a.m. cortisol 423 nmol/​L
Which one of the following is the most appropriate step with regard to
his further management considering he remains asymptomatic?
A. No follow-​up required
B. Repeat MRI of the pituitary after 4 months
C. Repeat MRI of the pituitary after 1 year
D. Repeat MRI of the pituitary/​anterior pituitary hormone profile after 4 months
E. Repeat MRI of the pituitary/​anterior pituitary hormone profile after 1 year

49. A 35-​year-​old woman was reviewed at the endocrine clinic on a

follow-​up visit. She had been incidentally diagnosed as having a
pituitary incidentaloma measuring 5 mm following investigations for a
possible benign intracranial hypertension about 6 months before. She
complained of recurrent episodes of headache together with visual
disturbance during this visit. On examination, she had bitemporal
superior quadrantanopia. Repeat MRI showed significant increase in the
size of pituitary tumour, with compression of the optic chiasm.
Investigations:
IGF-​1 12 nmol/​L (16–​118)
Prolactin 950 mU/​L (60–​620)
FT4 10.6 pmol/​L (11.5–​22.7)
TSH 0.5 mU/​L (0.35–​5.5)
9 a.m. cortisol 401 nmol/​L
Which one of the following is the most appropriate next step in her
management?
A. Cabergoline
B. Neurosurgical referral
C. Radiotherapy
D. Thyroxine
E. Thyroxine and GH therapy
28 Chapter 1 | QUESTIONS

50. A 16-​year-​old was reviewed in a joint paediatric to adult endocrine

transition clinic. He was diagnosed as having craniopharyngioma at
age 14 years and underwent surgical removal of the tumour. Post-​
operatively, he was noticed to have delayed growth (as evidenced by his
height being two standard deviations (SDs) below normal, compared
with other children his age). Both his parents were of average height and
none of his siblings were of short stature. On an insulin tolerance test, a
peak GH value of 3 mU/​L (1 µg/​L) was seen.
Investigations:
0-​hour cortisol 308 nmol/​L
30 minutes post-​ACTH 592 nmol/​L
IGF-​1 12 nmol/​L (16–​118)
Prolactin 145 mU/​L (45–​375)
Testosterone 11.2 nmol/​L (8.5–​28.5)
TSH 2.6 mU/​L (0.35–​5.5)
Which one of the following is the most appropriate approach for
potential GH therapy in his case?
A. Confirm the GH deficiency by a second dynamic test
B. GH replacement is contraindicated considering the history of craniopharyngioma
C. GH replacement is not required as the dynamic test results are normal
D. Start on GH replacement
E. Start on GH replacement only if he is symptomatic

51. A 20-​year-​old woman was referred to the endocrine clinic with a

history of persistent headache over the previous year. Her examination
showed evidence of a left temporal visual-​field defect. Subsequent
anterior pituitary functions confirmed secondary hypothyroidism and
hypogonadotrophic hypogonadism. MRI of the pituitary showed a 4 ×
2 cm cystic parasellar lesion, which was compressing the optic chiasm.
CT scan of the head showed calcification in the sellar region.
Which one of the following is the likely diagnosis based on her clinical
profile?
A. Craniopharyngioma
B. Germinoma
C. Neurosarcoidosis
D. Pituitary adenoma
E. Teratoma
 Chapter 1 | QUESTIONS 29

52. A 23-​year-​old woman presented to the endocrine clinic with a 6-​week

history of headaches, extreme fatigue, and malaise. She was in the post-​
partum period, having delivered 3 months before. Her general physical
and systemic examination was unremarkable. MRI of the pituitary
showed an enhancing mass with thickening of the pituitary stalk and loss
of posterior pituitary bright spot.
Investigations:
0-​hour cortisol 55 nmol/​L
30-​minute cortisol (post-​synthetic 135 nmol/​L
ACTH injection)
Prolactin 801 mU/L (100–​550)
FT4 9.2 pmol/​L (11.5–​22.7)
TSH 0.1 mU/L   (0.35–​5.5)
Which one of the following is the most likely diagnosis?
A. Langerhans cell histiocytosis
B. Lymphocytic hypophysitis
C. Neurosarcoidosis
D. Pituitary adenoma
E. Sheehan’s syndrome

53. A 60-​year-​old man underwent elective trans-​sphenoidal surgery for

a non-​functioning macroadenoma compressing the optic chiasm. His
post-​operative recovery was uneventful. Post-​operative day 1 blood test
results were as shown:
Na 144 mmol/​L (135–​145)
K 4.0 mmol/​L (3.5–​5.5)
Urea 8.5 mg/​dL (7–​20)
Creatinine 110 µmol/​L (60–​115)
FT4 12.0 pmol/​L (11.5–​22.7)
TSH 0.8 mU/​L (0.35–​5.5)
9 a.m. cortisol 88 nmol/​L
Which one of the following is the most appropriate immediate step in
his management?
A. Formal visual-​field assessment
B. Hydrocortisone and thyroxine replacement
C. Hydrocortisone replacement
D. Insulin tolerance test
E. Observation
30 Chapter 1 | QUESTIONS

54. A 70-​year-​old man underwent elective trans-​sphenoidal surgery for

a NFPA, which was compressing the optic chiasm. On post-​operative
day 3, he complained of polydipsia and polyuria. His urine output was
noticed to be more than 5 L over a period of 24 hours.
Investigations:
Na 148 mmol/​L (135–​145)
K 4.6 mmol/​L (3.5–​5.5)
Urea 20.5 mg/​dL (7–​20)
Creatinine 124 µmol/​L (60–​115)
Calcium 2.71 mmol/​L (2.2–​2.6)
Random glucose 8.4 mmol/​L
Which one of the following is the most likely aetiology for his symptoms?
A. Central salt-​wasting syndrome
B. Nephrogenic diabetes insipidus (DI)
C. Primary hyperparathyroidism
D. Psychogenic polydipsia
E. Transient cranial DI

55. A 55-​year-​old man complained of an intermittent clear discharge from

the nose on a routine follow-​up visit to the endocrine clinic. He was a
known patient with NFPA who had undergone elective trans-​sphenoidal
surgery about 6 weeks previously. Post-​operatively, he had developed a
cerebrospinal fluid leak that required a surgical repair.
Which one of the following is the most appropriate step in his
immediate management?
A. Analyse the nasal discharge for β-​transferrin
B. CT angiogram
C. ENT referral for nasal endoscopy
D. MRI of the pituitary
E. Urgent neurosurgical intervention
 Chapter 1 | QUESTIONS 31

56. A 45-​year-​old man was diagnosed as having acromegaly and underwent

elective trans-​sphenoidal surgery. Post-​operatively, his symptoms of
headaches, sweating, and arthralgia persisted. His repeat IGF-​1 levels
remained elevated, together with unsuppressed growth hormone levels
on a glucose tolerance test. As a result, he was started on medical
therapy in the form of octreotide long-​acting preparation injections, and
repeat surgery was planned.
Which one of the following is a side effect/​complication associated with
octreotide treatment?
A. Development of renal stones
B. Impaired glucose tolerance
C. Increase in gall bladder contractility
D. Increase in pituitary tumour size
E. Increase in prolactin levels

57. Pasireotide (SOM 230) is a somatostatin analogue, which is approved

for treatment of adult patients with surgically incurable Cushing’s
disease. It has also been shown to be an efficacious agent in the medical
management of patients with acromegaly.
Which one of the following clinical/​physiological features is associated
with pasireotide (SOM 230) therapy?
A. Increased risk of development of renal stones
B. Increase in GH levels
C. Increase in IGF-​1
D. Selective inhibition of somatostatin receptor subtype 2 and 4
E. Worsening of glycaemic control in patients with diabetes
Another random document with
no related content on Scribd:
el llanto
que quasi tiene mi ánimo
deshecho?
Sólo á Syreno cuento sin
provecho
mi triste desventura,
que della tanto cura
como el furioso viento en
mar insano
las lágrimas que en vano
derrama el congojado
marinero,
pues cuanto más le ruega,
más es fiero.

No ha sido fino amor, Syreno

mío,
el que por estos campos me
mostrabas,
pues un descuido mío ansí
le ofende.
¿Acuérdaste, traidor, lo que
jurabas
sentado en este bosque y
junto al río?
¿pues tu dureza agora qué
pretende?
¿No bastará que el simple
olvido emiende
con un amor sobrado,
y tal, que si al passado
olvido no aventaja de gran
parte
(pues más no puedo
amarte,
ni con mayor ardor
satisfacerte)
 por remedio tomar quiero la
muerte?

Mas viva yo en tal pena, pues

la siento
por ti, que haces menor toda
tristura,
aunque más dañe el ánima
mezquina.
Porque tener presente tu
figura
da gusto aventajado al
pensamiento
de quien por ti penando en ti
imagina.
Mas tú á mi ruego ardiente un
poco inclina
el corazón altivo,
pues ves que en penas vivo
con un solo deseo
sostenida,
de oir de ti en mi vida
siquiera un no en aquello
que más quiero.
¿Mas qué se ha de esperar
de hombre tan fiero?

¿Cómo agradesces, dime, los

favores
de aquel tiempo passado
que tenías
mas blando el corazón, duro
Syreno,
cuando, traidor, por causa
mía hacías
morir de pura envidia mil
pastores.
 ¡Ay, tiempo de alegría! ¡Ay,
tiempo bueno!
Será testigo el valle y prado
ameno,
á do de blancas rosas
y flores olorosas
guirnalda á tu cabeza
componía,
do á veces añadía
por sólo contentarte algún
cabello:
que muero de dolor
pensando en ello.
Agora andas essento
aborresciendo
la que por ti en tal pena se
consume:
pues guarte de las mañas
de Cupido.
Que el corazón soberbio, que
presume
del bravo amor estarse
defendiendo,
cuanto más armas hace, es
más vencido.
Yo ruego que tan preso y tan
herido
estés como me veo.
Mas siempre á mi deseo
no desear el bien le es buen
aviso,
pues cuantas cosas quiso,
por más que tierra y cielos
importuna,
se las negó el Amor y la
Fortuna.
Canción, en algún pino ó dura
 encina
no quise señalarte,
mas antes entregarte
al sordo campo y al
mudable viento:
porque de mi tormento
se pierda la noticia y la
memoria,
pues ya perdida está mi vida
y gloria.

La delicada voz y gentil gracia de

la hermosa Diana hacía muy clara
ventaja á las habilidades de su
tiempo: pero más espanto daba
ver las agudezas con que
matizaba sus cantares, porque
eran tales, que parescían salidas
de la avisada corte. Mas esto no
ha de maravillar tanto los
hombres que lo tengan por
impossible: pues está claro que
es bastante el Amor para hacer
hablar á los más simples pastores
avisos más encumbrados,
mayormente si halla aparejo de
entendimiento vivo é ingenio
despierto, que en las pastoriles
cabañas nunca faltan. Pues
estando ya la enamorada pastora
al fin de su canción, al tiempo que
el claro sol ya comenzaba á dorar
las cumbres de los más altos
collados, el desamado Marcelio,
de la pastoril posada despedido
para venir al lugar que con Diana
tenía concertado, descendió la
cuesta á cuyo pie ella sentada
estaba. Vióle ella de lejos, y calló
su voz, porque no entendiesse la
causa de su mal. Cuando
Marcelio llegó donde Diana le
esperaba, le dijo: Hermosa
pastora, el claro día de hoy, que
con la luz de tu gesto amaneció
más resplandeciente, sea tan
alegre para ti como fuera triste
para mí si no le hubiesse de
passar en tu compañía. Corrido
estoy en verdad de ver que mi
tardanza haya sido causa que
recibiesses pesadumbre con
esperarme; pero no será este el
primer yerro que le has de
perdonar á mi descuido, en tanto
que tratarás conmigo. Sobrado
sería el perdón, dijo Diana, donde
el yerro falta: la culpa no la tiene
tu descuido, sino mi cuidado,
pues me hizo levantar antes de
hora y venir acá, donde hasta
agora he passado el tiempo, á
veces cantando y á veces
imaginando, y en fin entendiendo
en los tratos que á un angustiado
espíritu pertenescen. Mas no
hace tiempo de deternos aquí,
que aunque el camino hasta el
templo de Diana es poco, el
deseo que tenemos de llegar allá
es mucho. Y allende de esto me
paresce que conviene, en tanto
que el sol envía más mitigados
los rayos y no son tan fuertes sus
ardores, adelantar el camino, para
después, á la hora de la siesta, en
algún lugar fresco y sombrío tener
buen rato de sossiego. Dicho
esto, tomaron entrambos el
camino, travesando aquel
espesso bosque, y por alivio del
camino cantaban deste modo:

MARCELIO
Mudable y fiero Amor, que mi
ventura
pusiste en la alta cumbre,
do no llega mortal
merescimiento.
Mostraste bien tu natural
costumbre,
quitando mi tristura,
para doblarla y dar mayor
tormento.
Dejaras descontento
el corazón: que menos daño
fuera
vivir en pena fiera
que recebir un gozo no
pensado,
con tan penosas lástimas
borrado.

DIANA
No te debe espantar que de tal
suerte
el niño poderoso
tras un deleite envíe dos mil
penas.
Que á nadie prometió firme
reposo,
sino terrible muerte,
llantos, congojas, lágrimas,
cadenas.
En Libya las arenas,
ni en el hermoso Abril las
tierras flores
no igualan los dolores
con que rompe el Amor un
blando pecho,
y aun no queda con ello
satisfecho.

MARCELIO
Antes del amoroso
pensamiento
ya tuve conoscidas
las mañas con que Amor
captiva y mata.
Mas él no sólo aflige nuestras
vidas,
mas el conoscimiento
de los vivos juicios arrebata.
Y el alma ansí maltrata,
que tarde y mal y por
incierta vía
allega una alegría,
y por dos mil caminos los
pesares
sobre el perdido cargan á
millares.

DIANA
 Si son tan manifiestos los
engaños
con que el Amor nos
prende,
¿por qué á ser presa el
alma se presenta?
Si el blando corazón no se
defiende
de los terribles daños,
¿por qué después se queja
y se lamenta?
Razón es que consienta
y sufra los dolores de
Cupido
aquel que ha consentido
al corazón la flecha y la
cadena:
que el mal no puede darnos
sino pena.

Esta canción y otras cantaron, al

cabo de las cuales estuvieron ya
fuera del bosque, y comenzaron á
caminar por un florido y deleitoso
prado. Entonces dijo Diana estas
palabras: Cosas son maravillosas
las que la industria de los
hombres en las pobladas
ciudades ha inventado, pero más
espauto dan las que la naturaleza
en los solitarios campos ha
producido. ¿A quién no admira la
frescura deste sombroso bosque?
¿quién no se espanta de la
lindeza de este espacioso prado?
Pues ver los matices de las
libreadas flores, y oir el concierto
de las cantadoras aves, es cosa
de tanto contento que no iguala
con ello de gran parte la pompa y
abundancia de la más celebrada
corte. Ciertamente, dijo
Marcelio, en esta alegre soledad
hay gran aparejo de
contentamiento, mayormente para
los libres, pues les es licito gozar
á su voluntad de tan admirables
dulzuras y entretenimientos. Y
tengo por muy cierto que si el
Amor, que agora, morando en
estos desiertos, me es tan
enemigo, me diera en la villa
donde yo estaba la mitad del
dolor que agora siento, mi vida no
osara esperado, pues no pudiera
con semejantes deleites amansar
la braveza del tormento. A esto no
respondió Diana palabra, sino
que, puesta la blanca mano
delante sus ojos, sosteniendo con
ella la dorada cabeza, estuvo
gran rato pensosa, dando de
cuando en cuando muy
angustiados suspiros, y á cabo de
gran pieza dijo ansí: ¡Ay de mí,
pastora desdichada! ¿qué
remedio será bastante á consolar
mi mal, si los que quitan á los
otros gran parte del tormento
acarrean más ardiente dolor? No
tengo ya sufrimiento para encubrir
mi pena, Marcelio; mas ya que la
fuerza del dolor me constriñe á
publicarla, una cosa le agradezco,
que me fuerza á decirla en tiempo
y en parte en que tú solo estés
presente, pues por tus generosas
costumbres y por la experiencia
que tienes de semejante mal, no
tendrás por sobrada mi locura,
principalmente sabiendo la causa
della. Yo estoy maltratada del mal
que te atormenta, y no olvidada
como tú de un pastor llamado
Syreno, del cual que en otro
tiempo fuí querida. Mas la
Fortuna, que pervierte los
humanos intentos, quiso que,
obedesciendo más á mi padre
que á mi voluntad, dejasse de
casarme con él, y á mi pesar me
hiciesse esclava de un marido
que, cuando otro mal no tuviera
con él sino el que causan sus
continuos é importunados celos,
bastaba para matarme. Mas yo
me tuviera por contenta de sufrir
las sospechas de Delio con que
viera la preferencia de Syreno, el
cual creo que por no verme,
tomando de mi forzado
casamiento ocasión para
olvidarme, se apartó de nuestra
aldea, y está, según he sabido, en
el templo de Diana, donde
nosotros imos. De aquí puedes
imaginar cuál puedo estar,
fatigada de los celos del marido y
atormentada con la ausencia del
amado. Dijo entonces Marcelio:
Graciosa pastora, lastimado
quedo de saber tu dolor y corrido
de no haberle hasta agora sabido.
Nunca yo me vea con el deseado
contento sino querría verle tanto
en tu alma como en la mía. Mas,
pues sabes cuán generales son
las flechas del Amor, y cuán poca
cuenta tienen con los más fuertes,
libres y más honestos corazones,
no tengas afrenta de publicar sus
llagas, pues no quedará por ellas
tu nombre denostado, sino en
mucho más tenido. Lo que á mí
me consuela es saber que el
tormento que de los celos del
marido recibías, el cual suele dar
á veces mayor pena que la
ausencia de la cosa amada, te
dejará algún rato descansar, en
tanto que Delio, siguiendo la
fugitiva pastora, estará apartado
de tu compañía. Goza, pues, del
tiempo y acasión que te concede
la fortuna, y alégrate, que no será
poco alivio para ti passar la
ausencia de Syreno libre de la
importunidad del celoso marido.
No tengo yo, dijo Diana, por tan
dañosos los celos, que si como
son de Delio fueran de Syreno, no
los sufriera con sólo imaginar que
tenían fundamento en amor.
Porque cierto está que quien ama
huelga de ser amado, y ha de
tener los celos de la cosa amada
por muy buenos, pues son claras
señales de amor, nascen dél y
siempre van con él acompañados.
De mí á lo menos te puedo decir
que nunca me tuve por tan
enamorada como cuando me vi
celosa, y nunca me vi celosa sino
estando enamorada. A lo cual
replicó Marcelio: Nunca pensé
que la pastoril llaneza fuesse
bastante á formar tan avisadas
razones como las tuyas en
cuestión tan dificultosa como es
ésta. Y de aquí vengo á condenar
por yerro muy reprobado decir,
como muchos afirman, que en
solas las ciudades y cortes está la
viveza de los ingenios, pues la
hallé también entre las
espessuras de los bosques, y en
las rústicas é inartificiosas
cabañas. Pero con todo, quiero
contradecir á tu parescer, con el
cual heciste los celos tan ciertos
mensajeros y compañeros del
amor, como si no pudiesse estar
en parte donde ellos no estén.
Porque puesto que hay pocos
enamorados que no sean
celosos, no por eso se ha de decir
que el enamorado que no lo fuere
no sea más perfecto y verdadero
amador. Antes muestra en ello el
valor, fuerza y quilate de su
deseo, pues está limpio y sin la
escoria de frenéticas sospechas.
Tal estaba yo en el tiempo
venturoso, y me preciaba tanto
dello, que con mis versos lo iba
publicando, y una vez entre las
otras, que mostró Alcida
maravillarse de verme enamorado
y libre de celos, le escribí sobre
ello este

Soneto.
Dicen que Amor juró que no
estaria
sin los mortales celos un
momento,
y la Belleza nunca hacer
assiento,
do no tenga Soberbia en
compañía.
Dos furias son, que el bravo
infierno envía,
bastantes á enturbiar todo
contento:
la una el bien de amor
vuelve en tormento,
la otra de piedad la alma
desvía.
Perjuro fué el Amor y la
Hermosura
en mí y en vos, haciendo
venturosa
y singular la suerte de mi
estado.
Porque después que vi
vuestra figura,
ni vos fuistes altiva, siendo
hermosa,
ni yo celoso, siendo
enamorado.
Fué tal el contento que tuvo mi
Alcida cuando le dije este soneto,
entendiendo por él la fineza de mi
voluntad, que mil veces se le
cantaba, sabiendo que con ello le
era muy agradable. Y
verdaderamente, pastora, tengo
por muy grande engaño, que un
monstruo tan horrendo como los
celos se tenga por cosa buena,
con decir que son señales de
amor y que no están sino en el
corazón enamorado. Porque á
essa cuenta podremos decir que
la calentura es buena, pues es
señal de vida y nunca está sino
en el cuerpo vivo. Pero lo uno y lo
otro son manifiestos errores, pues
no dan menor pesadumbre los
celos que la fiebre. Porque son
pestilencia de las almas, frenesía
de los pensamientos, rabia que
los cuerpos debilita, ira que el
espíritu consume, temor que los
ánimos acobarda y furia que las
voluntades enloquesce. Mas para
que juzgues ser los celos cosa
abominable, imagina la causa
dellos, y hallarás que no es otra
sino un apocado temor de lo que
no es ni será, un vil menosprecio
del propio merescimiento y una
sospecha mortal, que pone en
duda la fe y la bondad de la cosa
querida. No pueden, pastora, con
palabras encarescerse las penas
de los celos, porque son tales,
que sobrepujan de gran parte los
tormentos que acompañan el
amor. Porque en fin, todos, sino
él, pueden y suelen parar en
admirables dulzuras y contentos,
que ansí como la fatigosa sed en
el tiempo caloroso hace parescer
más sabrosas las frescas aguas,
y el trabajo y sobresalto de la
guerra hace que tengamos en
mucho el sossiego de la paz, ansí
los dolores de Cupido sirven para
mayor placer en la hora que se
rescibe un pequeño favor, y
cuando quiera que se goze de un
simple contentamiento. Mas estos
rabiosos celos esparcen tal
veneno en los corazones, que
corrompe y gasta cuantos deleites
se le llegan. A este propósito, me
acuerdo que yo oí contar un día á
un excelente músico en Lisbona
delante del Rey de Portugal un
soneto que decía ansi:

Quando la brava ausencia un

alma hiere,
se ceba, imaginando el
pensamiento,
que el bien, que está más
lejos, más contento
el corazón hará cuando
viniere.
Remedio hay al dolor de quien
tuviere
en esperanza puesto el
fundamento;
 que al fin tiene algún premio
del tormento,
o al menos en su amor
contento muere.
Mil penas con un gozo se
descuentan,
y mil reproches ásperos se
vengan
con sólo ver la angélica
hermosura.
Mas cuando celos la ánima
atormentan,
aunque después mil bienes
sobrevengan,
se tornan rabia, pena y
amargura.

¡Oh, cuán verdadero parescer!

¡Oh, cuán cierta opinión es ésta!
Porque á la verdad, esta
pestilencia de los celos no deja en
el alma parte sana donde pueda
recogerse una alegría. No hay en
amor contento, cuando no hay
esperanza, y no la habrá, en tanto
que los celos están de por medio.
No hay placer que dellos esté
seguro, no hay deleite que con
ellos no se gaste y no hay dolor
que con ellos no nos fatigue. Y
llega á tanto la rabia y furor de los
venenosos celos, que el corazón,
donde ellos están, recibe
pesadumbre en escuchar
alabanzas de la cosa amada, y no
querría que las perfecciones que
él estima fuessen de nadie vistas
ni conocidas, haciendo en ello
gran perjuicio al valor de la
gentileza que le tiene captivo. Y
no sólo el celoso vive en este
dolor, mas á la que bien quiere le
da tan continua y trabajosa pena,
que no le diera tanta, si fuera su
capital enemigo. Porque claro
está que un marido celoso como
el tuyo, antes querria que su
mujer fuesse la mas fea y
abominable del mundo, que no
que fuesse vista ni alabada por
los hombres, aunque sean
honestos y moderados. ¿Qué
fatiga es para la mujer ver su
honestidad agraviada con una
vana sospecha? ¿qué pena le es
estar sin razón en los más
secretos rincones encerrada?
¿qué dolor ser ordinariamente
con palabras pesadas, y aun á
veces con obras combatida? Si
ella está alegre, el marido la tiene
por deshonesta; si está triste,
imagina que se enoja de verle; si
está pensando, la tiene por
sospechosa; si le mira, paresce
que le engaña; si no le mira,
piensa que le aborresce; si le
hace caricias, piensa que las
finge; si está grave y honesta,
cree que le desecha; si rie, la
tiene por desenvuelta; si suspira,
la tiene por mala, y en fin, en
cuántas cosas se meten estos
celos, las convierten en dolor,
aunque de suyo sean agradables.
Por donde está muy claro que no
tiene el mundo pena que iguale
con esta, ni salieron del infierno
Harpías que más ensucien y
corrompan los sabrosos manjares
del alma enamorada. Pues no
tengas en poco, Diana, tener
ausente el celoso Delio, que no
importa poco para passar más
ligeramente las penas del Amor. A
esto Diana respondió: Yo vengo á
conoscer que esta passión, que
has tan al vivo dibujado, es
disforme y espantosa, y que no
meresce estar en los amorosos
ánimos, y creo que esta pena era
la que Delio tenía. Mas quiero que
sepas que semejante dolencia no
pretendí yo defenderla, ni jamás
estuvo en mí: pues nunca tuve
pesar del valor de Syreno, ni fuí
atormentada de semejantes
passiones y locuras, como las
que tú me has contado, mas sólo
tuve miedo de ser por otra
desechada. Y no me engañó de
mucho este recelo, pues he
probado tan á costa mía el olvido
de Syreno. Esse miedo, dijo
Marcelio, no tiene nombre de
celos, antes es ordinario en los
buenos amadores. Porque
averiguado está que lo que yo
amo, lo estimo y tengo por bueno
y merescedor de tal amor, y
siendo ello tal, he de tener miedo
que otro no conozca su bondad y
merescimiento, y no lo ame como
yo. Y ansí el amador está metido
en medio del temor y la
esperanza. Lo que el uno le
niega, la otra se lo promete;
cuando el uno le acobarda, la otra
le esfuerza; y en fin las llagas que
hace el temor se curan con la
esperanza, durando esta reñida
pelea hasta que la una parte de
las dos queda vencida, y si
acontesce vencer el temor á la
esperanza, queda el amador
celoso, y si la esperanza vence al
temor, queda alegre y bien
afortunado. Mas yo en el tiempo
de mi ventura tuve siempre una
esperanza tan fuerte, que no sólo
el temor no la venció, pero nunca
osó acometella, y ansi recibía con
ella tan grandes gustos, que á
trueque dellos no me pesaba
recebir los continuos dolores; y fuí
tan agradescida á la que mi
esperanza en tanta firmeza
sostenía, que no había pena que
viniesse de su mano que no la
tuviesse por alegría. Sus
reproches tenía por favores, sus
desdenes por caricias y sus
airadas respuestas por corteses
prometimientos.
Estas y otras razones passaron
Diana y Marcelio prosiguiendo su
camino. Acabado de travessar
aquel prado en muy dulce
conversación, y subiendo una
pequeña cuesta, entraron por un
ameno bosquecillo, donde los
espessos alisos hacían muy
apacible sombrío. Allí sintieron
una suave voz que de una dulce
lira acompañada resonaba con
extraña melodía, y parándose á
escuchar, conocieron que era voz
de una pastora que cantaba ansí:

Soneto.
Cuantas estrellas tieue el alto
cielo
fueron en ordenar mi
desventura,
y en la tierra no hay prado ni
verdura
que pueda en mi dolor
darme consuelo.
Amor subjecto al miedo, en
puro hielo
convierte el alma triste ¡ay,
pena dura!
que á quien fué tan contraria
la ventura,
vivir no puede un hora sin
recelo.
La culpa de mi pena es justo
darte
á ti, Montano, á ti mis quejas
digo,
alma cruel, do no hay
piedad alguna.
Porque si tú estuvieras de mi